Christus Homecare - St Michael

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care contained the required elements to include all supplies and equipment required, patient specific interventions and education, and safety measures to protect against injury for 1 of 17 patient reviewed for plan of care. (Patient #1) The agency did not ensure the POC included the type and location of Patient #1’s dialysis access or where and when Patient #1 went to dialysis treatments. The Plan of care did not include orders to monitor or assess Client #1’s dialysis site for complications or signs and symptoms of infection. This failure could result in Patient #1 not receiving proper care/instruction to the dialysis access site and could lead to complications/hospitalization and could cause a lack of coordination of care or missed visits. Findings included: Record review of a plan of care dated 2/11/2025 to 4/11/2025, indicated Patient #1 was admitted to the agency on 12/13/2024 with diagnosis including high blood pressure, congestive heart failure (condition where the heart muscle is weakened and does not pump blood effectively), end stage renal disease (condition where the kidneys have permanently lost their ability to function properly) and encounter for extracorporeal dialysis catheter (a temporary or permanent medical device inserted into a large vein to provide access to the blood stream for dialysis). The plan of care did not indicate where Patient #1’s dialysis catheter was located or where and when Patient #1 received dialysis (a procedure that filters the blood to remove waste and extra fluid when the kidneys aren’t working properly). During an interview on 3/5/2025 at 9:11 a.m., RN A said she was a field nurse for the agency. RN A said she developed the plan of care and then it was sent electronically to the office for the administrator/DON to review. RN A said the plan of care should include to monitor the dialysis fistula or catheter, where the dialysis catheter was located and when and where the patient received dialysis. RN A said this was important because the dialysis site needed to be monitored by the nurse to make sure there are no complications. During an interview on 3/5/2025 at 9:37 a.m., RN B said she worked as a field nurse and developed plan of cares and also reviewed plan of cares in the office. She said the plan of care should include orders to monitor a client’s catheter or shunt site at each nurse visit. RN B said the POC should also include where the catheter or shunt was located and when and where the patient received dialysis. RN B said the POC should indicate the name of the dialysis clinic and the phone number of the clinic. RN B said these orders were important so the nurse could monitor the catheter or shunt site for any complications. During an interview on 3/5/2025 at 12:08 p.m., the administrator/DON said Patient #1’s POC should have included interventions for her dialysis treatments and catheter to include the site of the catheter. The administrator/DON said Patient #1 had a dialysis catheter located on her right upper chest. The administrator/ DON said the POC should have included orders to assess the dressing site for any complications or signs and symptoms of infection/complications and name and phone number or the dialysis clinic to report any issues. The administrator said it was important for the POC to include these interventions for overall patient care and coordination of care. The administrator/DON said she reviewed the plan of cares, and this plan of care should have included the dialysis interventions. Record review of a policy titled Plan of Care revised on 09/01/24, indicated its purpose was to assure an appropriate plan of care is developed and revised in a timely manner for each patient. To ensure that physician/authorized practitioners orders are followed. The policy indicated the POC included: F. medications and treatments, g. safety measures to protect against injury, I. patient specific interventions and education; measurable outcomes and goals identified by agency and patient; j. required equipment and supplies, n. all patient care orders.”